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Um we're gonna move on to. Uh And so I think she's um she was a CEO of global and no government organization scale access to treatment. She's also ap working one day a week and a 20 minutes at hospital. Watson Town is an advanced practice physiotherapist in pediatric orthopedics at Chelsea and Westminster. While she lead the home, she was involved in education and train for health care professional in the man in the UK. And a, she was involved in the development of the Foot train program with global and part of the UK consensus group and is a trustee of Available. It's fine. Thank you for the intro. Um Just let me know if you can hear me. My voice is going a bit today. Um But yeah, thanks for introducing us and for a really amazing, interesting day so far. Um As you have heard from the introduction, we're all about Club Foot. So I've got a question for you first. Um Who here knows anyone living with Clubfoot? Anyone in the audience? One person. Interesting. So club that affects about one in 800 people. So you'd think that probably between us, we would we could expect to know quite a few people living with club. Um But what happens in this country is that it gets treated at birth. Um There's very low awareness of it as a condition because the treatment is so effective. Um But in the rest of the world that doesn't happen routinely and that's what we're trying to change. So that's what we'll be talking to you about today. Um But Denise is gonna start us off with some of the details of how we treat blood first and what it is. Thank you. Um I can probably just use this can, can you hear at the back? Yeah. Ok. So, I mean, probably the most famous person with club foot was Lord Byron, but he's obviously not alive today and I hopefully the treatment's moved on a little bit from when he was born. So um it's a complex deformity of the foot and about 180,000 new cases are born every year. So it's a significant number. But what's really shocking is that 90% of those are in the low and middle income countries because that's where the highest birth rate is. Um It's about one in 800 the prevalence actually somewhere between one and 801 in 1000. Um And that is a little bit different depending on uh where the population is, but it's 2.5 times more common in boys than in girls. And there is a genetic element to it, but it's very complicated and we don't really know much about that side yet. So pre sort of 1985 1990 Clubfoot treatment was very high cost. Uh, it was really not on offer in low income countries at all. It involved uh significant amounts of surgery. This is a postal media release, very, very skilled operation. High cost and you had pretty brutal orthotics or an even more high cost, which of us to use something like this brain actually need none of these things give. In fact, none of these methods here give good results. Um And um later surgery, um they tended to go up into later surgery because they were stiff, painful feet with progressive deformities. So, although it was high cost, it wasn't uh highly successful. And then this man came along. So he was a, a Spanish surgeon working in Iowa and he just um amazingly managed to unpick the conundrum of Clubfoot. So he com he unpicked the conundrum as a subtalar joint manipulation. He understood that how collagen worked. He'd been in research and he recognized it was really important to put some principles down and stick to them. Um He realized that the, the, the surgical part of the treatment could be performed uh under local anesthetic. And so that brought the cost of the treatment right down. So that's an achilles tendon tono. Uh He realized that bracing was essential. So much like with orthodontic treatment. If you don't wear retainers after your teeth have been straightened. If you don't wear bracing after club foot treatment, his feet will go back into an old position. Um And when he wrote up his 30 year follow up, his results far exceeded those of the, the higher cost surgical procedures. So this was our journey at Chelsea and Westminster. So we moved into Poti treatment in 2001. We just did it. We didn't ask, we just went back to patients and said, if we could treat you without surgery, would you let us have a go? And they said yes, so we did. Um and we saw 60 to 10, 6 to 10 new babies every year at that stage, we now see 100 and 20 new babies every year. Not because there's a bigger percentage in the population, but we get referred Children from all over the country who have more complex feet or choose to come here. Um It's a physiotherapy led service, but it's really a multidisciplinary team. So we've got fantastic consultants, clinical nurse, specialist healthcare assistants. Um and it's all about being trained and any, it doesn't have to be a specific discipline. It's all about training. Um And we have a special interest at Chelsea and Westminster in those cases which fail to progress or have relapsed and are coming to us for a second opinion. So it's really simple. The basic treatment involves gentle manipulation of the foot, a series of above knee casts, which could be anything between three and six weeks, you change the casts weekly. And then, um, and the baby, you can see this baby here with five natural above knee cast on, they're probably about two or three casts into the treatment at this stage as opposed to that foot. Ok. So that foot's become something like that. Um And then as I say, the surgery is very simple. It's a percutaneous achilles tendon, toomy, more than 90% of the cases we see will need that procedure. And it's a complete division of the achilles tendon. We do it in clinic with local anesthetic and normally with the parent sitting next to the baby if they're under six months. Um, and then that posttenotomy would go back into cast and the posttenotomy stays on for 2 to 3 weeks. Like somebody made some faces thinking it sounded gruesome, but actually, it's so much better for the child not to have to have a general anesthetic and it takes seconds. So this is a really low cost serial casting, achilles tendon annoy back into cast. And then really important thing. Once the casts are, uh, removed, the child has to wear this bracing for three months, 23 hours a day, but then just at nighttime and naps until they're between four and five years of age. Um, and, um, it looks pretty scary for parents at the beginning, but the Children just get used to it. And the, and the, what's great is that there'll be a normal footwear during the day. So during daytime, once they're walking, they won't have to wear special shoes. They'll just wear these at night time when they go to sleep. We'd expect them to have normal function and we'd expect them to have mobile pain free feet at the end of the treatment. So, um what Denise was describing was how the way we treat club foot has shifted here at Chelsea and Westminster. And that's actually been a global paradigm shift in the way that um treatment occurs. And I, I'm not sure are there any orthopedic surgeons in the room or anyone who deals with club foot in your job? No. So um so, II guess what we wanted to do with this talk as well about telling you about club foot, we wanted to talk about scaling up um access to an innovative treatment worldwide. Um And the role of an NGO in that because we thought that would be kind of applicable to everyone across um the audience. Um But what we saw as Denny said in the early two thousands was was that this incredibly effective and low cost treatment started to be accepted as the gold standard of treatment uh worldwide. And that was when it started to be used here in the UK. Um At the same time, we saw a couple of early adopting low income countries, um starting to try and implement this treatment on a, on a national scale. So Uganda Malawi were some of the first ones and they really proved that this could be disseminated across the country. Um You could make sure that clinics were in all the big population centers and that it was something that was causing a huge problem. A huge burden of disability could actually effectively um be dealt with in infancy. And we've done a lot of work since then. Um to figure out what it costs and exactly what needs to be put in place to make it happen. Um But that was really why we started Global Club Foot initiative because we saw that it could be done. And when, when we saw that, we thought, well, why not every child in the world then why should any child um live with this um really crippling impairment for their whole life when actually, you know, it could have been dealt with at birth. Um So we set up as an umbrella organization to bring people together um around this vision and to coordinate geographically. Um We've grown from, I think it's three founding, no, two founding NGO S to 60 NGO S over about um 12 years. And our network now includes all of the major NGO S that support the treatment of Children with Clubfoot. Um They're supporting the treatment of around 35,000 Children every year. And working in the 70 low and middle income countries. So a very good geographical reach and we're talking about treating club foot. Um, if you don't treat it, this is what it looks like. So you see how there's family um, in Ethiopia, um, a mum and her two Children. Um, it looks like the Children probably have had some treatment. Um, but maybe dropped out or, or maybe, um, the boy might not have started, the mum has not had any treatments. And what that will do in a person's life is that they will experience severe stigma um across their community, they'll have severe physical impairment. Um They won't be able to go to school for the most part, that means lost employment opportunities that impacts economically on society as they grow. Um And we know that all Children with disabilities in lower middle or in all countries actually are at increased risk of discrimination and abuse. Um So some really big challenging consequences from this deformity. Um One of the things we do at Global Comfort Initiative is we try and map out where the progress is happening. Um That's one of the key um ways we advocate and I know a lot of the speakers this morning were talking about the importance of evidence and data in making your case. Um So we've mapped this over the years. This is actually quite an old map from 2017. Um We're in the process of updating it. But what this shows is that actually there's not a bad geograph spread of some treatment availability and it's improved since this map was made. But that coverage within countries is still really low. And what our latest data tells us is that around 20% of Children are now getting treatment in infancy, which means that the other 80% are still not. And we estimate that there's about 2.5 million Children under the age of 18, living with untreated club. So up to 2023 where did we get to? Um So this is starting from the early two thousands. Um So over about 20 years, 350,000 Children have started treatment to date. 70 countries are now offering some onset treatment in those 70 countries live. 80% of all the Children we'd expect to be born with club foot. So the geographical coverage and the opportunity for treatment is really vastly vastly improved um in 20 years. Um and the results from treatment are really good. So this um 99% are able to walk after four years after starting treatment and there's really high parent satisfaction. Um So it really is kind of proof that it's a treatable condition and that it can be done on a wide scale and some of the most challenging countries um in the world to implement health care, Bangladesh, Tanzania, Zimbabwe, Rwanda, they're now treating 50 to 70% of all um new cases of club for every year. So it really is um a good news story, but there's also a lot of work still to be done. Um This is again on mapping right there. Oh no. Oh, there we go. So this, this shows how the numbers have increased over the years. So what we're aiming for is is scale up. We wanna see this, this curve going up really rapidly. Um You can see there went a really rapid up to up until about 2017, 19. Um We got to around 20%. The science of scale up tells us that the first uptake is generally usually fairly easy to achieve. And then you get to a point where it becomes more difficult because then you have to start integrating it um into existing services. So we had a little bit of a plateau here. Um There was also, this really shows us the importance of partnerships and healthy partnerships because there was some big partnership problems with some of the big NGO S involved. And II would say a lot of this plateau here was down to that. Um Then we had COVID which I said they won't mention but did this morning that caused that plateau. Um But our latest data tells us that we're now off, we're somewhere up in the ceiling, we've got to about 40,000 kids in 2023. Um So things are looking good for coming out of COVID that recovery and really starting to see that that scale up happening again. Um So the big needs in cancer and actually, these are so similar um to what the other presenters spoke about this morning. Um you know, the awareness that is actually treatable. So we call that the demand side. Um The demand for treatment continues to be really low in a lot of places. Um We hear parents telling us that, you know, the child was born, the birth defect was noted, but no one in the hospital knew it was treated treatable. So they were told to just take their child home and care for them as best they could. So there's really a low awareness that needs to change. Um There's also we find a, a really challenging kind of lack of political will and um because this is a kind of multisectoral um thing that needs, that needs to be joined up care across a bunch of sectors that's quite challenging as well to sort of figure out who really owns this as a problem. And when we go to the World Health Organization, who should we be speaking to? Because um is it the surgery department, the maternal and child health, the rehabilitation or the assistive technology because it processes all of those. But because it's a relatively small thing compared to many other problems, it's very difficult to get someone to own that issue. So there's a lack of political will we obviously need to expand geographical reach while deepening coverage and really raise the profile of this as a priority. The other thing that we know about scale up is that when things scale rapidly, um there's often a decrease in quality um that can happen very easily. So we have to be really, really on it with quality, measuring our outcomes. And the N GS that we work with have made some really amazing um systems for being able to do that with data capture in the clinic. And then clinicians being able to use that to improve their treatment quality. And then of course, the big one heightening integration within existing health services, something that we all talk about, we all aim for but actually takes a lot of time and advocacy to actually make that happen. Um So typically, um again, the way that scale up happens is it's often driven by individuals or NGO S of the society at the start. But then it gets to a point where it can't really progress unless it becomes integrated into systems. And that's what we're seeing at the start. There was a few individual orthopedic surgeons that really became champions for this and championed it globally. They made an enormous difference, but now it's gone beyond that. Now it has to actually be in systems. Um So there's a video that is only two minutes long, but this will really summarize what we're talking about in the three minutes the baby is born with, that's nearly 200,000 babies each year. Output is a def that easily be it. In each year. 80% of them is going to watch because they live in countries where they no a for the treatment as, as Children with pain discrimination and rejection with little hope for the future. But future free from disability, you want to, every child will comfort, you run free for disability. By 2030. As a global Clubfoot community, we develop 13 2030 a strategy to a club as a life on disability service delivery model for B treatment is simple and in and 1 2013 to be available in new clinics in all countries around the world. We provide the training conditions and monitor treatment outcomes. So we know that babies get the best possible treatment, be part of natural health care systems to make sure that their health workers have the skills they need that are always well stocked, close to the Children they need and the families have a long term support, they need to grow into healthy Children, bright futures, we need your help too. Doing this, make it possible for all Children to run by. So yeah, as they, as they said, we've got a global strategy for a scale up um of Clubfoot treatment worldwide. Um The four kind of pillars of it are expanding geographical coverage, raising the profile of Clubfoot retaining focus on quality and integration. Um And this access model describes how this is implemented on a country level. Um What we've found is that to scale up, we need to have, we need to break down what we're doing into parts that can then be replicated or scaled on, on a country level. So the treatment actually lends itself really well to that. Um What we've got at the heart of this model is the child and their family. And it's so important to understand um their challenges and what they're going through. Um I think the guy who talked about skin this morning, talked a lot about um poverty and how that impacts on what we're able to do. We find exactly the same challenge here. Um You know, coming to the clinic week after week is really, really difficult. And so we really have to understand our patients. Um The treatment takes up to five years, they have to wear braces up to five years, but it's very, very effective. Um We have a service delivery model that covers all the things that need to happen around treatment to make it successful. Um So things like early detection and referral, um establishing clinics, close to populations, training, clinicians, supply chains, monitoring, evaluation, et cetera. And then the wider environment really affects how successful we are. And we either have to be able to adapt this model to the environment or we need to change the environment. So it's more favorable um to us so that we're able to make progress. And that includes things like population awareness, infrastructure, political will, and medical community acceptance, as well as the very big um issues of poverty et cetera, which will take time to change. Um So here's a, a case study and I think this is really interesting how well this ties in with um some of the presentations this morning. Um But what happened in Ethiopia was that the local NGO partner um was talking to the Ministry of Health and discovered that they were about to run a door to door campaign looking for cases of measles. Um And so they, so they asked if they could train those people to look for Clubfoot at the same time. Um And they did so and they identified over 3000 Children living out in the community with untreated Clubfoot. Um Now they have the challenge of treating all those Children. Um because as discussed this morning, you can't just go and find something and then not offer anything. Um So this is a really great example because it's shows how even in a country where there's a very good program for club foot and there is in Ethiopia, there's just still so many patients that we miss. It shows the importance of early referral, early identification and it shows the importance of working with government. And as one of the speakers mentioned earlier as well, working with other conditions, not just focusing only on what we're trying to do. Um, we've already alluded to the fact that treating P is inexpensive. Um, we've costed it out globally average. Um, cost is around $500 per child. Um, for the whole course of treatment. Um, when you work out averages of what that child might earn in their lifetime, um, either if they didn't have treatment and when they have, um, we find that treating one child for $500 can bring about $130 of earning potential to that individual over their lifetime. Um which is a return on investment of 260 times. Um The initial investment, which is a really, really compelling economic argument, isn't it? Um So Denise is gonna tell you a bit about our training program, which she's been really involved in. Thanks Ros. So it's all, it's, you've got to have good quality of care to keep these standards up. And so I've been, and I have been very fortunate to be involved with um developing a training program which was in initially developed uh as an Africa Clubfoot training. And actually, it's been such a successful tool. It's, we've now adapted it very slightly for a high income setting as well. Um So uh it consists of uh three courses. There's a training, the trainers and then there's a basic level one course, two day course and a and a level two, which is slightly more advanced and we now have a third really exciting course, um which both Ross and I have been involved with this year. Um looking at Delayed Presenting Club Foot. So those are the Children, the older Children that haven't had treatment and are in training these, these, some of these more experienced practitioners to deal with that problem as well. Um And so far we've rolled this training out to 53 different countries. So, um and it's, it's become a standard here in the UK. You get uh it's, it's validated by the Royal College of Surgeons in the UK. And um uh so you actually get CPD points. So we have learnt a lot of lessons from developing the training and they're not necessarily ones that we expected. Um So the training materials are hugely important um as part of the, the whole package um to build that effective com foot care. So we have models, we have, we have rubber foot models, we have skeleton models, we have training journals and we have lots of online information reading packs for people before they start the training. Um definitely helps to be it's sustainable and it's helping to build capacity within the health system. So that the more people that we have trained, the more their confidence grows that that's more sustainable with treatment. And actually we really look to sort of pick out um what we call Ponti champions. So people that are really gonna take this and run with it in their country and really motivate other people. Um And that's part of ongoing monitoring and evaluation of and quality improvement are absolutely vital to the success. So we have things like we have a AAA knowledge and skills matrix that we use at the beginning and end of each course to look at the what, what perception of what people have, where they've gained in confidence and knowledge that's been a really useful way to show that the course is effective. And I think nice for people to see how their own results have improved. Um But you really need this supervision and mentoring to go beyond the course. I mean, it's a two day course, it's not going to, it's not going to lead to you being an expert. So actually then using all the people that attend the course to mentor and support each other and, and feed into some of the more experienced practitioners within the the country um or outside country is very important and actually, it's built a real um global community of er club foot care. So I think we were going to look at some of these questions. Yeah. So these are some questions that organizers sent us and I thought they were really interesting. Um How much time have we got left? Eight minutes. OK. Um So yeah, we thought maybe um just generally speaking about um setting up an NGO as a clinician would be interesting um to you as well. So the first question um was what does setting up an NGO look like? Um When we set up the Global Clubfoot initiative, I was a very um young and inexperienced physiotherapist. Um I went to work in a hospital in Malawi um and joined the Club foot. Well, I was told here's a manual read it. You've got Club Foot Clinic tomorrow. The next day I turned up and the waiting room was absolutely packed with families and we just spent the whole day um casting and putting braces on, on tiny feet. Um But from that kind of grew this, this global vision um along with the other um founding and, and trustees. Um and it's been a, a hugely hugely rewarding process. Um I would say to be working towards such a big global goal and vision um that could change so many lives is, is incredibly exciting. Um When I look at that graph of all the kids um being enrolled in treatment, I think, you know, as an umbrella organization, it's actually very difficult to measure our impacts and outcomes. But even if we've only made a tiny difference to the percentage there that's still um 100s of lives changed. And so, yeah, it's just incredibly rewarding um and seeing it in clinic, um we treat babies together every week and um seeing those little feet kind of come round and, and straighten out um is just as exciting. Actually. Um It has been a huge learning curve for someone for myself. I was trained as a clinician. I, that was my main job. Um I didn't have any experience of running a charity. Um I've had to learn about strategy, finance, hr charity, law, fundraising, how to form partnerships, um marketing and communication. Um And everything else that NGO S have to think about. Um coming from the NHS I think interestingly, my, probably my biggest gap or my biggest blind spot was around um communications and marketing. Um because at least in the services I've worked in, in the NHS, we don't have to do much of that. Um People just come to us when they need us and to make a shift from, from having that to actually having to go there out, convince people, persuade people um was a really big um change. I've also noticed there's lots of transferrable skills from working as a clinician. Um problem solving, monitoring and evaluation, um resourcefulness um having a really deep understanding of patients views and experiences. Um And if I ever want to know about a bit more about that, I can just ask my patients in the clinic um on the phone. So, and um being able to be an effective advocate for patients as well, I think um as clinicians, we're really, really good at that. Um And I'd say there's connections with the clinical world with um top notch clinicians like Denise and others that we work with, um has really benefited us as a charity as well. Um Other things we've learned, we have a, a great board of trustees. Um as I mentioned in our talk that was initially mainly championed by clinicians um by clinicians who kind of saw a change in their own practice, mostly orthopedic surgeons, actually who've done lots and lots of operating on babies feet um in their careers and then saw the lives, um, decided not to operate on, on babies with Clubfoot anymore and then became, um champions um for onset treatment and they were really the early drivers of this change. Um, but then over time, we, you know, that's not enough anymore. We have to have all of these other skills on board. And so we've, we've had to move, um along with that, um, setting up an X and seeing at work takes a huge amount of time if I'd known 12 years ago how long it would take? I don't know if, I don't know if I would have started. Um And there's a constant balance as an NGO between what I would call survival and doing the things you actually want to do that, you know, make a difference. Um So the survival is all the kind of admin and logistics and the fundraising. So you have to pay your staff somehow. And then once you've done all of that, just to make sure that you're legal and compliant and you survive, then you can sort of um cream off a bit of the take off a bit of time at the top to actually do the things that, that really, that really matter. Um So yeah, that's um a big law and there's a saying that I find particularly resonates, um which is that most people overestimate what they can achieve in a year and underestimate what they can achieve in 10 years. And I think that's really, really true. So if you are thinking about being part of an NGO helping an NGO don't underestimate what you can do over time. You add anything to that first thing that, that really sums it up. Thank you. OK. Um So we keep going on. Um So what was the thinking behind setting up global Comfort initiative for a low resource setting? Um The thinking behind it really at the start was driven by this really stark injustice that um club Foot is treatable. It's feasible to treat it in a low income setting and it's not happening. Um So that's just a huge injustice. And um as people that know how to treat club foot, it felt like we should be doing something about that. Um What, what else? OK. We'll go to that one next year. So what's transpired over time is that as an umbrella organization? And again, we kind of set this up, not really knowing what umbrella organizations do or how they work um but we thought we'll, we'll give it a go because we've seen that when organizations work together and use the different strengths that they have, they actually can produce more than they would on their own. Um But what we've seen is that, you know, treating 35,000 kids every year, the NGO S in our network are only spending about $15 million on that. That's incredibly, incredibly efficient for any type of intervention. But for an intervention where, you know, it's gonna have a lifelong effect as big as um Clubfoot treatment does. That's just a, a really actually very small amount of money. Um Our next milestone is 2030 we need to double the number of kids um by then and double the amount of funding. Um So we jump to the final question then. Um Den, do you wanna speak to that one first? And then I'll add a few comments. Oh, sure. OK. I'll go first because I have notes. Um So what roles and opportunities are there for M MDT members navigating a career in global health? Um So I would say get experience working overseas but definitely go to learn. Um And I would say go for as long as possible if you're serious about it and like stay in one place, get in bed, really stay there and learn. Um where clinicians have helped us so much is through being champions and advocates um doing conference presentations inviting us to conferences um using their clinical and expert connections as well. Um I'm not someone who has a really good network of contacts that I can go to for influence or funding, but through the the clinicians that we know in our network, that makes a huge difference. So if you have a network user that can be huge. Um II think the thing that I would add is the value added of having also as a clinician here at Chelsea and Westminster and me as a clinician at Chelsea and Westminster with global Club foot both organizations massively gain from that from that partnership as well. So it's really driven us to improve things both in the UK and abroad. And we've now got this training set up in both in both areas and consensus in the UK, which is being used as evidence in low income countries as well. And it's um so it's been a little value added, being able to work together in both settings. Yeah. Yeah, we need to stop. Ok. I've got examples of what good um volunteering looks like and bad volunteering looks like. Um So if you'd like to hear them come and ask me afterwards. So in time.